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ARRANGEMENTS CONNECTED WITH THE

RELIEF OF THE SICK POOR;

ADDRESSED

IN A LETTER

TO

THE RIGHT HONOURABLE THE LORD JOHN RUSSELL,

SECRETARY OF STATE FOR THE HOME DEPARTMENT,

BY JOHN YELLOLY, M.D. F.R.S.

PHYSICIAN TO HER ROYAL HIGHNESS THE DUCHESS OF GLOUCESTER ;
LATE PHYSICIAN TO THE LONDON HOSPITAL, &C.

THE SECOND EDITION WITH ADDITIONS

L 0 N D O N :

PRINTED FOR

LONGMAN, REES, ORME, BROWN, GREEN, AND LONGMAN,

PATERNOSTER ROW,

18.37.

WORCESTER :

PRINTED BY HENRY DEIGHTON AND CO.

JOURNAL OFFICE.

The Author has much pleasure in complying with the
kind and flattering wish expressed by the Council of the
Provincial Medical Association , that his Letter should
appear in the fifth volume of the Transactions of that
respectable and influential body ; and he has availed him¬
self of the opportunity which has thus been afforded him ,
of making some alterations and additions.

As a Committee of the House of Commons has been
appointed to inquire into the operation of the Neiv Poor
Laws , the Author has every expectation , that through their
means, and under the auspices of the distinguished indi¬
vidual to whom his Letter is addressed , a very material
improvement will be made in the medical arrangements
connected with the sick poor of this country .

April 8, 1837,

4

■i

-41

*

V

OBSERVATIONS, &c.

My Lord, —

I am induced to trouble your Lordship, with some observa¬
tions on the arrangements connected with the relief of the Sick

o

Poor in this country, from a high sense of the importance of
the subject, and a firm conviction that it is very imperfectly
understood.

I am quite aware that your Lordship's attention has been
already directed to the inquiry, by a great variety of publica¬
tions and appeals ; and am sensible too, that a Statesman
engaged in managing the affairs of a great nation, has little
time for an examination of details, and must often be satisfied
with transferring the investigation of them to others.

To these circumstances I may add, that so much has been
already written on the subject, as to leave little of novelty for
observation or remark. But in the face of all these consider-

6

THE RELIEF OF

ations, I venture to think, that it may he serviceable to the
cause of fair and candid inquiry, that a person who has been
in no way mixed up with the previous discussions ; who has
never been connected with the management of workhouses or
houses of industry, and may therefore be supposed to be in a
considerable degree free from the prejudices to which such a
connection is often imagined to give rise ; and who has no
sort of personal interest in the question, should take a general
view of the whole matter of investigation.

These are the grounds on which I take the liberty of ad¬
dressing your Lordship ; but there are one or two additional
points, which it may not be unbecoming or irrelevant to notice.
Many years of Dispensary and Hospital practice, as well as
the habit which I have pursued all my life, of seeing poor .
persons at my own house, have afforded me ample opportuni¬
ties of becoming acquainted with the character and necessities
of the more indigent classes of society, and in some degree
with their modes of thought and action. I have likewise had
the satisfaction of enjoying a very extensive acquaintance with
all classes of practitioners, both in town and country ; and
have possessed more than ordinary means of becoming con¬
versant with their merits and qualifications. Entertaining’
therefore, as I do, very strong feelings as to the necessity
which exists for some improvement in the management of the
Sick Poor ; and thinking, likewise, that as a part of such
improvement, a more liberal procedure to the professional
persons who are engaged in attending them, would be both
politic and just, I consider it as in some degree approaching
to a duty on my part, to endeavour to assist, in the evening
of life, and retirement from practice, in correcting what appear
to me mistaken ideas, in that very important department of
the public service, which relates to the administration of me¬
dical relief to the necessitous. I likewise indulge the hope,
that if your Lordship, in the high station which you occupy,
as regulator of the domestic affairs of this kingdom, should
be induced to devote your attention to an examination of
the subject in all its bearings and relations, the result would

THE SICK POOR.

7

be eminently favourable to the interests of humanity, as far as
the poor are concerned, and particularly gratifying to the feel¬
ings of the large, useful, and influential body of men, who
form the medical practitioners of the United Kingdom.

I have long been of opinion, that much ill-judged parsimony
has attached to the medical arrangements connected with the
Sick Poor ; and that, while the expenditure of parishes was
conducted on a large and unrestricted, if not, (according to the
common opinion), a profuse and lavish scale, the medical de¬
partment, in which the interests of humanity are so much
involved, and which formed only a very small item ot the
general account, was regulated with inconsiderate and incon¬
sistent penuriousness. Under such disparity, it may well
be said, — -

“ Vehemens in utramque partem, Menedeme , es nimis,

Aut largitate nimid , ant par simonid.

In eandem fraudem, ex hdc re, atque eoc ilia, incides.”

I took the liberty of offering a strong opinion on the sub¬
ject, in my examination before the Committee on Medical
Education in the early part of 1834, having long previously
wished that the subject might be brought under the cogni¬
zance of Parliament, by some well-informed and public-spirited
Member.*

V,

* With reference to medical attendance on the poor in the country,
is there any information you wish to give to the Committee? — I think
nothing can be worse than that which is adopted in parishes very
generally ; it would be exceedingly desirable if legislative measures
could be adopted which would enable the poor to have more efficient
advice than they can have at present.

Is the point to which you allude that of farming out the medical
attendance upon the poor to the lowest bidder ? — It is.

Does that prevail extensively in that part of the country in which
you reside ? — There is an incorporation which comprises above forty
parishes, and four medical men attend ten parishes each, at the
rate of only £4 per parish. Even in opulent parishes near London,
the surgeon is sometimes beat down by competition, to a stipend
which could not admit of his doing the duties properly.

8

THE RELIEF OF

When the new system of poor laws was introduced, I in¬
dulged the expectation, that, under their influence, the plan of
medical attendance on the poor would be rendered more effi¬
cient and satisfactory. This has not however been the case,
and I regret that the Commissioners, for whose talents and
character I entertain the highest respect, have early appeared
to me, to have fallen into some misconceptions relative to me¬
dical men and medical practice, which it is the more necessary
should be the subject of temperate and dispassionate observa¬
tion, because the same views are sustained in the second
report which has lately appeared, and which comes forward
with that augmentation of force and authority, to which the
increased experience of its authors may naturally be supposed
to entitle it.

Anxiety to obtain professional employment has occasionally
led young and efficient men, but much more frequently the
ill-educated and ignorant, to unworthy compromises of the
respectability of the profession. Previously to the year 1815,
when the Apothecary's Bill came into operation, any one
might call himself a surgeon and commence practice ;* and as
we know how imperfectly even the best informed members of

Have any of those points ever come under your own observation in
any parishes? — Certainly, I have known many inadequate payments.
1 have seen now and then inattention ; hut generally I am very happy
in saying, that I think the profession at large do themselves great
credit by giving more attendance and medicine than the amount of
stipend at all remunerates them for.

Is it generally the practice in your part of Norfolk to farm the
poor? — It is always the practice if there are not hundred-houses;
hut when there are hundred-houses, which unite many parishes to¬
gether, the surgeon is remunerated better by the number, than if he
had one parish only at the same rate of payment.

Is the price paid very often such as will not more than pay for the
medicines? — Decidedly. I have heard of £5 being given at some
miles distant: some of the medical men of Norwich have had parishes
to attend at a distance of some miles, for not much more than that rate.

* It may he proper to state, that by surgeon , I here mean the
general practitioner , who practises all the branches of the medical
profession.

THE SICK POOR

9

society are often able to appreciate the merits of medical men,
it not unfrequently happened, that the more worthy practi¬
tioner was either supplanted, or obliged to lower the terms of
attendance on parochial patients to such an extent, as did not
admit of his doing them justice without a great personal sacrifice.

The vulgar and ignorant practitioners, who had insinuated
themselves into the profession previously to 1815, are, it is
true, fast wearing out ; for no one is now permitted to practise,
without a proper education, and a due examination into his
qualifications ; but the feeling of keeping medical remuneration
for parochial services as low as possible, still continues ; nor
does it appear that the amount of such remuneration, is ever
determined by the sort of estimate, which the common sense
of mankind leads them to employ in the regulation of their
ordinary expenses.

In matters of common business, men generally consider the
quantum meruit of him whom they employ. The labourer they
regard as worthy his hire ; and while they feel it to be their
duty to resist imposition, they have no kind of disinclination
to pay fairly for efficient services. But in parochial medicine
the case is different ; for the only point aimed at, seems to be
that of having the care of the sick poor undertaken as cheaply
as possible, without its being a matter of consideration whether
the contract can defray the expense of proper medicines, still
less that of affording anything like an adequate remuneration
for time and trouble. But medical men are found to attend
parishes on the low and inadequate terms mentioned, and the
regulators of the affairs of the poor are generally satisfied, to
refer this circumstance to the legitimate operation of compe¬
tition, of which they perhaps consider themselves bound to
take advantage.

The principle of competition, and the contracts to which it
gives rise, are considered by many, as applicable to every sort
of public arrangement. I venture, however, to call in question
the justness of the reasoning in reference to a great variety of
concerns ; and feel it, therefore, to be an important object of
my present address, to submit to your Lordship some con si-

10

THE RELIEF OF

derations, with a view to shew that the position is inaccurate,
and its practical operation, as far as medical affairs are con¬
cerned, unsafe and inexpedient.

When the question relates to articles of known and palpa¬
ble character, proposals and contracts afford the means of
obtaining them at the lowest possible rate. There can there¬
fore be no objection to such modes of effecting business ; for
while we may be sure that the parties will not go below the
rate which will allow them a reasonable profit, the honest
fulfilment of the contract is capable of being ascertained, by a
moderate degree of attention and judgment on the part of a
principal or his agents.

If a work of magnitude is concerned, as the erection of a
house, or the building of a ship, a contract is equally applica¬
ble ; but in this case, as the principal has rarely the time and
the judgment necessary for enabling him to ascertain whether
justice is done to him or not, he generally finds it necessary to
employ some one to watch over his interests. In such an
axample however, my Lord, it would be considered as alto¬
gether out of the question, to look to the lowest terms at
which inspection and superintendance could be obtained, in¬
stead of selecting a person on whose judgment and assiduity
dependence could be placed for efficient assistance and pro¬
tection.

Nor would any one, I am sure, make competion and low
charges ingredients in his choice of a solicitor, who is to be
entrusted with the management of his most important private
affairs ; or of an engineer, who is to devise or carry into
effect momentous operations, whether of a public or private
nature ; or of the fabricator of that nice and curious machinery,
which, in the trackless ocean, enables man to pursue his way
with confidence and accuracy ; but his aim would be, by a
judicious selection in the first place, and liberal treatment in
the next, to ensure the full exercise of the most faithful, and
most able services.

In all these cases it is not a common operation which is
required, or an article of obvious character which is to be

THE SICK POOH.

if

provided ; but it is the intellect, the spark of divine essence,
which we wish to enlist in our service ; the exercise ot unfet¬
tered zeal, assiduity, and talent, which would be chilled and
repressed by any thing like illiberality and suspicion. To
propose that pecuniary competition should be allowed to
operate in appointing the officers of our fleets and armies,
in providing for the sacred duties of religion, or in filling up
the departments of the State or Diplomacy, would be just as
objectionable as is the plan now so frequently adopted relative
to attendance on the sick poor ; where the usual principles
which actuate human proceedings in all the ordinary concerns
of life, are so singularly and entirely overlooked.

If a tradesman or artisan were to offer to provide an article
of known value, at a rate at which it could not be afforded,
there would at once appear to be something underhand and
suspicious in the transaction. The proposition would be
viewed as offensive and disreputable ; for though competition
may be employed to ascertain the lowest value at which a
thing can be provided, the greatest stickler for economy would
never think of offering’ a sum which he knew was totally

inadequate to procure the article in question. There would
thus be the appearance of a temptation to obtain it in a
fraudulent way.

And yet with regard to the parish surgeon, he is required
either to accept a sum which the least consideration or inquiry
will evince to be totally inadequate ; or he is desired to give
in his proposals, which he knows must be within certain pre¬
scribed limits ; or he is threatened with a competition, by the
introduction of some new practitioner into his district, which
must in some degree risk a still further reduction of his hardly
earned income, than the crowded state of the profession has
yet occasioned. I here is no disposition to reward according
to services, but the ungenerous feeling is too generally enter¬
tained, to employ the very hardships under which the profes¬
sion labours by the numbers who enter it, as a means of still
further depression. I have remarked that the parsimony is
inconsistent, and that it applies to an article of comparatively
small amount. This appears from the appended statistical

12

THE RELIEF OF

notices, to which l request your Lordship's attention;* and
from them I think it may he fairly inferred, that if medical

* At Norwich with 61,118 inhabitants, the poor-rates have varied
within the last few years from about 20,000 /> to 29,000/. per annum;
and for the last year were 15,700/. The expenses of medical attendance
during the same period have remained at about 300/. per annum, the
medicines being made up by an apothecary, at a salary of 100/. per
annum, (which is included in this sum,) in a house hired for the
purpose ; but the poor being attended by medical gentlemen gra¬
tuitously. If the four gentlemen in attendance had an allowance of
50/. per annum each, which would make the whole expense relative to
the poor of all descriptions about 500/. per annum, the system would,
1 understand, he very efficient and satisfactory.

In former times, when the annual expenditure was seldom less than
30,000/., four medical gentlemen gave attendance and medicine by
contract at about 80/. per annum each, besides an allowance for
vaccination, and the power of charging for suspended orders.

In an Union in my own neighbourhood, consisting of the two
Hundreds of Loudon and Clavering, in Norfolk, having a popula¬
tion of 13,680, containing 86 square miles of surface, and paying-
poor-rates of about 90001. per annum, wffiich have been reduced, as
appears by the Commissioner’s reports, to 6494/., the attendance and
medicines were long contracted for by four gentlemen at 40/. per
annum, or 160/. in the whole, with the payment of at first 2 s. per
mile, which was reduced to Is. for visiting distant poor, (that is poor
out of the Hundred) and 2s. 6d. each for vaccination; but the whole
sum is now made 210/. per annum, without any other sources of
emolument. This is at the rate of 15/. per 1000 of population, and
12/. for every 5 square miles of surface.

In a contiguous Union, that of W angford, in Suffolk, consisting of
27 parishes, having a population of 13,058, containing 55 square miles
of surface, and expending, on an averge of three years, up to 1835,
9852/. per annum, exclusive of migration and emigration expenses,
a sum which was reduced last year to 5720/., three medical gentlemen
received 172/. per annum in the whole, for medical attendance on all
paupers in the Union, whether they belonged to it or not, without
further emolument, and to find every thing except trusses, which is
the case with all the other contracts mentioned. This wras at the
rate of 13/. per 1000 of population, and 15/. for every 5 square miles
of surface. But the terms have lately been reduced to 158/. per
annum, w hich is at the rate of 12/. per 1000 of population, and 14/. for
every 5 square miles of surface. I am acquainted with the Chairman

attendance were even adequately remunei
form but a small item of general parochial

•ated, it would still
expenditure.

and several of the Directors of the last two Unions, and their report
of the success of the arrangements adopted under the new poor
laws, is very favourable.

The Hundred of Forehoe, in Norfolk, consists of 22 parishes,
has 13,533 inhabitants, comprises 60 square miles of surface, and
in former years expended about 7500/. per annum on the poor.
The medical attendance was long contracted for at 120/. per annum,
with one medical gentleman, who engaged some assistance in executing
the business. This was at the rate of 9/. per 1000, or 10/. for 5 miles
of surface. The district has been lately put under the charge of four
surgeons, who are paid 160/. per annum, or in the ratio of 12/. per
1000, and 13/. for 5 square miles.

The Union of St. Faith’s, near Norwich, consists of 32 parishes,
of 11,126 inhabitants, of 70 square miles of surface, and pays 10,833/.
poor-rates. The medical attendance is contracted for at 170/. per
annum by four surgeons, two of whom live at Norwich. This is at
the rate of 15/. per 1000, and 11/. for 5 square miles.

Costessey, four miles from Norwich, with 1098 inhabitants, 3150
acres, or near 5 square miles of surface, used to be attended by a
Norwich surgeon for 6/. per annum. It is now united with tli e
Forehoe Union.

Depwade Union, in Norfolk, consists of 43 parishes, has 24,678
inhabitants, 110 square miles of surface, pays 24,008/. to the poor-
rates, and is attended by four medical gentlemen at 100/. per
annum each, which is at the rate of 16/. per 1000 inhabitants, and
18/. per 5 miles of surface.

Thetford Union, in Norfolk, has 34 parishes, 16,198 inhabitants,
174 square miles of surface, pays 10,833/. of poor-rates, has three
medical gentlemen who contract for medical attendance at 270/. per
annum, which is at the rate of 17/. per 1000, or 8/. for every 5 square
miles. The Contractors, with the permission of the Guardians, have
five other medical gentlemen associated with them, in the performance
of their duties, which is found to be in every way advantageous.

Swaffham Union, in Norfolk, consists of 32 parishes, 12,632 in¬
habitants, 125 square miles of surface, pays 12,545/. poor-rates, and
has two medical gentlemen, who receive between them 230/. per
annum, or 18/. per 1000 of population, and 9/. per 5 square miles of
surface.

The very opulent parishes of Woodford, Walthamstow, Leyton,
Wanstead, Chingford, and Loughton, in Essex, have a population

14

ns E RELIEF OF

Though no reluctance is exhibited to trust the health of
hundreds, or of thousands of poor persons, to the care of gen¬
tlemen very imperfectly remunerated, yet I am persuaded that
matters stand somewhat differently, when the health of a man’s
own family is concerned. There is little probability, that in
such case, he would look out for his medical man, as he would
for a parish surgeon, on the sole or principal ground of cheap-

of 13,764, have 30 miles of surface, and paid 8118/. of poor-rates.
The medical attendance was formerly contracted for at about 280/.
per annum, of which about 22.5/. were for the four first named parishes.
But this last mentioned sum has been reduced to 155/. since these
parishes were put into the West Ham Union ; this is at the rate of
13/. per 1000, and 33/. for every 5 square miles.

For a short time the drugs in one of those parishes, containing a
population of above 4000 persons, were purchased by the parish, a
dispenser engaged at a small salary to make them up, and attendance
on the patients given by the resident surgeon gratuitously ; but yet,
though the expense of the drugs alone amounted to near 70/. per
annum, the Guardians, I understand, have felt themselves justified in
contracting for drugs and attendance together, at 50/. per annum.

In the Metropolitan parish of St. Leonard Shoreditch, consisting
of 68,564 inhabitants, and having an expenditure of 22,888/., three
gentlemen are engaged to attend the whole poor at 80/. per annum
each, including midwifery and suspended orders.

From a consideration of the statements now made, though only
approximating to accuracy, it is clear that the sum employed in the
medical department bears a very small proportion to the whole annual
expenses ; that a fair and proper recompense for medical services
would make too trifling an addition to such amount to be at all felt ;■
and that as the rates have been much diminished, and have the
prospect of being much more so, such an addition could be the better
spared.

In the instances given, the population amounts to 248,441, and the
sum paid for medical services to 2293/. At this rate, in the whole of
England and Wales, containing a population of near 14 millions, the
annual payment for the sick poor would be about 128,000/. per annum,
and therefore, at the present reduced amount of the poor’s-rate, as
given in the Commissioners’ report, (5,526,417/.) to a forty-second
part of the whole. Supposing, however, that the calculation made is
considerably below the truth, I am still justified in saying, that the

0

medical expenses, if fairly and considerately paid, would be only a
small part of the annual expenditure.

i ll \] SICK POOH.

15

ness, without his conjugal or parental solicitude being exercised,
to inquire whether justice could be done them on the terms
offered; and if he made a contract, and at the time of illness
and anxiety had the least idea of its not being sufficiently
liberal, there is no reason to imagine, that a considerate
husband or father, would suffer the letter of an engagement to
interfere with making such an alteration in the terms of it, as
might insure to his family every exercise of skill and attention,
of which the practitioner employed by him was capable. In
a question of mere property, there can be no doubt what
would be the procedure ; and that a cow doctor or a horse
doctor would be desired to do every thing possible for the
recovery of a sick animal, by the most efficient curative pro¬
cesses, without reference to the expense. I may remark, too,
that when slavery existed in our colonies (now, to the honour
of our nation, fortunately abolished for ever), feelings of
interest and humanity united in procuring every possible
attention to the health of the unfortunate subjects of it, which
the most liberal and efficient medical arrangements could
produce.

But there is, I presume, a feeling common with guardians
and parish officers, that if a medical gentleman can once be
induced to make a contract for parochial attendance, on terms
ever so unfavourable, he will execute his duties conscientiously
and efficiently. To the credit of the profession, I believe that
the exertion will always go beyond the remuneration, and
very often far beyond it ; but this must have a boundary, and
it does not appear to me humane to the patients, or proper to
the practitioner, to make it the interest of the latter to be as
sparing as possible of his medicines, and particularly of the
more expensive descriptions, and of every medicinal assistance
which it requires much time or trouble to impart.* It may

* It is impossible to expect that the ill-paid practitioner will
employ the more powerful and expensive medicines in the execution
of his contract ; as for example, quinine, Peruvian bark, iodine,
sarsaparilla, castor oil, citric acid or lemon juice, tinctures, or
aromatics ; and he has therefore the continual temptation before him

16

T II E RELIEF OF

be known whether a man has made a professional call ;
but though his attendance may be sufficient to satisfy the
expectations or demands of the church-warden, overseer, or
guardians, it still may not be what a man of zeal would
bestow, who feels that confidence is reposed in him, which he
is proud of possessing, and anxious to merit. As to medicines,
it is clear that as matters at present stand, there is no check
whatever in relation to them, except in the sentiments of
honourable obligation possessed by the party employed ; and

to make cheap substitutions. Lint, though so valuable as a dressing
in surgical cases, is expensive, and is therefore sparingly used ; but
as for leeches, for which there is no proper succedaneum in many
serious affections, it cannot be expected that he will incur the heavy
expense of providing them, if at all, in the adequate number and
frequency ; nor can he afford the time to do many little personal
offices, which may be eminently conducive to the comfort and well
doing of the sick, and which, if his sympathies were not in some degree
affected by the hard bargain forced upon him, humanity and profes¬
sional feeling might induce him to exercise.

The unworthy higgling process, to which a medical man must
therefore subject himself, before he can succeed in getting a contract
to attend the poor, are unheard of in other liberal professions ; and
the methods which he must adopt to make his contract answer, risk
the production of an unfavourable effect, as well upon his own per¬
sonal character and feelings, as upon those of the young men under
him, by shewing to the latter, that there is one set of medicines, mode
of prescription, and kind of attendance in operation for those who can
afford to pay for themselves, and another for such as are dependent on
the public for relief in sickness. — One of the Assistant Poor Law
Commissioners, Mr. Power, describes well the necessary consequence
of inadequate remuneration, at p. 26 7 of the Second Annual Report

on the Poor Laws, when he says, “ that the low scale of remuneration

* %

given , in proportion to the services exacted , has formed , in some instances ,
the excuse for defective attendance , and the supply of a worse description
of drugs than could safely he applied to the private patient;” and u has
made it difficult to the medical man , without great sacrifice , to attend
properly on the parish patients” Mr. Power makes these observations
on the presumption of a greater demand for professional services than
was contemplated on making the contract ; but they are equally
applicable under whatever circumstances the effect may have been

produced.

THE SICK POOR.

in

7

yet the conduct exercised to him, is not usually of that flatter¬
ing description, which conveys the idea of much of that sort
of feeling being presumed to exist.*

I am aware that the Poor Law Commissioners are disposed,
in their last report, to consider the principle of competition, as
“ strictly, and to the fullest extent, applicable to the supply
of drugs for the parish poor ; but I would beg leave respect¬
fully to state, that this can only be the case, when means are
afforded of judging whether such supply is correctly provided.
If an hospital or a dispensary purchase drugs by competition,
they have proper officers to see that the articles furnished are
good. In this case, and under such circumstances, the prin¬
ciple of competition strictly and fully applies ; but it does not
appear to me that it can do so with parochial attendance, when
there is no check, and can be none, on the medical man, as to
the quantity or quality of the medicines dispensed by him.

I have thus endeavoured to point out the inapplicability of
competition to provide sufficiently for medical attendance on
the poor ; and I may add, that the inadequate terms of re¬
muneration, give a lower rank to parish employment than it
ought to possess, and often prevent the more established and
best estimated practitioners of a district, from wishing to have
any share in it.

Of this circumstance I know, personally, several examples ;
and cannot help feeling it to be a subject of great regret, that
any want of liberality in medical arrangements, should risk

* A singular method has been adopted by the Guardians of an
Union in the county of Norfolk, for the purpose of securing the
attendance at the workhouse, of one of the medical gentlemen, a man of
great merit, who has the charge, at 50 1. per annum, of 8 parishes out
of 32, containing about 3000 inhabitants, at the distance of from two
to six miles from his residence. This is by a stipulation that he must
attend at such workhouse, (about four miles from his residence,) one
hour regularly every day, whether there is any duty requiring such
frequent attendance, or such a period of it, or not. How far the
thraldom and want of confidence that any such stipulations evince,
will be favourable to the interests of the sick poor, is well worthy the
particular attention of the Poor Law Commissioners.

B

18

THE RELIEF OF

depriving the poor, of the best advice which their locality
affords them.*

In comparing the plan which is adopted relative to the sick
poor, with the mode of conducting many of the other public
operations of the country, there are some singular and striking
incongruities, to which I request your Lordship’s attention.
It was no unusual thing, in former times, for parish poor, and
parish lunatics, to be farmed out ; but though much pains
were taken to see that justice was done them, the practice is
very properly almost entirely done away. The Government
and Parliament have long set themselves against any arrange¬
ments, whether medical or general, by which the full effect of
those provisions which they may think proper to adopt for the
public benefit, has not every chance of being received.

The medical attendance on prisons was formerly conducted
very much with a view to cheapness ; but when an enactment

* In my own neighbourhood, in the small towns of Beccles and
Bungay, the principal practitioners do not take parochial employ¬
ment ; and this is likewise the case at Norwich.— It is not the habit
of the profession, either in London or the country, for men of long
standing, great reputation, and large practice, to be the candidates
for even the most honourable public appointments ; and it would be
very difficult to fix on any rate of pecuniary recompense, which would
he a sufficient inducement for persons thus circumstanced to accept
such situations, supposing that they could even be obtained without
the labour and inconvenience of a canvass. It must be observed, too,
that from various circumstances, there is much difference in the feel¬
ings of practitioners in relation to parochial employment, and in the
urgency of the endeavours to obtain it. — If, however, sufficient in-
ducements to undertake official attendance on the poor, both as to
moderate pecuniary recompense, and honourable and liberal treatment,
are held out to young and middle aged men of superior education,
and good prospects in life, such persons would be likely, from habit
and attachment to their duties, to retain those appointments, (as is
often the case with regard to hospitals among the first men, both in
London and the country) far beyond the time at which they would
think of either soliciting or accepting them. In this way, the ultimate
effect would be, to augment the credit of parochial appointments, and
to ensure, as long perhaps as the complete period of active usefulness
might continue, the services of the most efficient and respected men.

THE SICK POOR.

was made, which showed that it was the wish of the legislature
to have efficient services, and to pay for them adequately, the
visiting magistrates raised the terms of remuneration to a fair
extent, and have by this means, pretty generally I believe,
now rendered the appointment of surgeons to prisons, one that
the most respectable members of the profession feel desirous
of obtaining.*

O

But the cases which I most wish to submit to your Lord¬
ship’s consideration, respect the medical and surgical depart¬
ments of the army and navy.

It was formerly the practice, for the surgeons to provide
their medicines, in both departments of the public service,
with a certain, and T have no doubt an adequate allowance for
the purpose ; Sir James Macgrigor, the Director General
of Military Hospitals, does me the favour to inform me, that
this practice was discontinued in the army about the ; year
1793; and Sir William Burnett, the Physician General
of the Navy, is so obliging as to state, that ffirom the year
1796, some of the most important medicines were furnished

* By the enactment of the 4th Geo. IV, c. 64, Justices have the
power to direct “ a reasonable sum to be paid as salary ” to the surgeon,
“and also such sums of money as shall he due for medicines, "and other
articles for the sick by which the principle of giving a proper
remuneration for services, separately from the value of the- medicines,
seems to be completely recognized. — The salary to the surgeon of
Norwich Castle, (the county goal) including medicines, was formerly
only 40/. per annum. It was then made 80/., and subsequently, I
believe, to the passing of this law> was increased to 120/., with a very
kind intimation from the visiting magistrates, that it would be further
increased if necessary. — At Bury St. Edmonds, the salary was for¬
merly only 40/. per annum ; it was afterwards made 60/., and|is now
100/.— The surgeon to the House of Correction and the New Prison,
at Clerkenwell, receives 300/. per annum salary, and 100/. for
medicines.

I may state likewise, that the stipends of clergymen to goals, were
very properly made more liberal by the same act ; but I have regretted
to see only 80/. per annum offered by some Unions for double duty,
when, under such circumstances, the ordinary payment to curates
would be 120/. per annum, and of chaplains to prisons, in a graduated
scale, from 1.50/. to 240/., or even more.

20

THE RELIEF OF

bv the then Sick and Hurt Board ; and that from the year
1805, the whole of the drugs were provided by Government,
and the pay of naval surgeons regulated by an order in Council
as it now stands.

Sir James Macghxgoe, mentions the old practice as being
“ fraught with evil consequences"; but if this were the case,
where the pecuniary allowance was liberal, and the oppor¬
tunities of inspection afforded, through the means of naval and
military discipline, ample ; much more is it likely to be so,
under the present circumstances of medical attendance on the
poor of the country generally. Caesar's wife ought not to he
suspected ; and 1 have no doubt that it was felt to be highly
desirable, to remove every possible opportunity of throwing
out suspicions of interested or mercenery conduct, against
naval or military medical gentlemen. Certain it is, that the
additional encouragement given in both departments by Go¬
vernment ; the kind protection afforded by naval and military
chiefs ; and the unwearied care and attention of the heads of
the Army and Navy Medical Boards, have infused among the
medical men of both services, so much enterprise, and so much
eagerness for professional distinction, as to have forwarded
much the scientific cultivation of the profession, and by this
means greatly tended to promote the interest of humanity. — It
is pleasing to see, in the medical profession, that men who have
incurred perils’, and endured hardships in the service of their
country, should be able, on their retirement, to take an
honourable position among the highest of their respective
ranks, and bring into civil life, augmented energy, information,
and experience.

Precisely the same plan is followed by the East India
Company ; and I am enabled to state, on the authority of
Mr. Melvill, the Finance Secretary, u that the medicines
employed for the troops in India, and for the Indian Navy,
are furnished wholly from the Government stores; the surgeons
having no pecuniary interest whatever in the supply."

It is of great importance to the general advantage of the
community, that the tone of feelings of the country surgeon

THE SICK POOR.

21

should be kept up, by a consideration of the elevated nature
of his studies and pursuits ; the important character of his

duties ; and by his having the example always before him, of
the eminent men who exercise the same profession which he
does, participate in the same feelings, and with whom he is
very probably conjoined as a member of some college or
corporation.

Under such impressions, he is far better prepared to main¬
tain the professional energy on which his patients are so de¬
pendent for their safety, in what may happen to be the most
sudden, dangerous, and difficult emergencies, than if he has
the feeling invariably presented to him, of his services being
inadequately estimated, and ungraciously and imperfectly
recompensed.*

* Most country surgeons,, even in the most remote districts, have
not only the qualifications which the Apothecary’s Act requires, but
are members of the Royal College of Surgeons, a rank which it is not
a matter of obligation, but which they feel to be creditable to possess.
Notwithstanding the humble duties which a superficial view of the
subject may induce some persons erroneously to attach to country
practitioners, their education, (the medical part of which embraces the
same objects in all the departments of the profession) the liberal objects
of their studies and associations, and the habits of observation which
their daily avocations produce, communicate to them very frequently, a
respectable character for information and intelligence, and sometimes
a well marked distinction for scientific and literary attainments. —
It is little known out of the profession, that some of the most
delicate and important operations of surgery, sometimes fall to the lot
of country surgeons; and I particularly allude to strangulated hernia ,
in which they may be called upon at any moment, to operate ; and in
which the loss of time, in sending to a distance, might cost a patient
his life.

Our provincial hospitals are well known to have furnished some of
the most expert operating surgeons of this or any other country ; but
in prosecuting some statistical researches, several years since, into the
tendency to calculous complaints, which were honoured with a place
in the Philosophical Transactions, I bad occasion to become acquainted
with the expertness and skill, as well as the enterprise and courage,
exhibited by many country practitioners, particularly in this part of
the kingdom where stone is so prevalent, in the performance of the

THE RELIEF OF

As the attendant of both the rich and the poor, the medical
man forms a useful medium of communication and reciproca¬
tion ; and it would be very important, in the execution of the
momentous duties which are entrusted to the Poor Law Com¬
missioners, that they should have the co-operation of the
medical profession throughout the country ; for it is not to be
forgotten, that on the humanity, judgment, and independence
of that body, the poor must hinge entirely, for their comfort
and well doing during indisposition.

With regard to the mode in which a change in the medical
arrangements could be effected, it would not be difficult to
assimilate the system of providing medicines for parishes, in
some degree with the method pursued in furnishing them for
the army and navy, or for hospitals and dispensaries. It
would be important to banish entirely the present plan of
making it the interest of a professional man to withhold the
medical aid that is proper ; and this, it appears to me, may
be readily effected, either by providing parishes or unions with
a certain supply of medicines, and awarding a remuneration
for attendance separately ; or if it be determined that one sum
shall still cover the whole, by making a proper estimate of the
value of the medicines necessary, and superadding a fair
remuneration for attendance and trouble.

Such an arrangement would be most readily effected with
the sanction of Government, through the means of the Poor
Law Commissioners. But it is a matter of grave and im¬
portant consideration, whether it would not be in proper
conformity with other parts of our social system, that there
should be a medical gentleman, of character and experience,
connected with the Poor Law Commission, and possessing
the confidence of the public and the profession, to study and

operation of lithotomy, when there is so much credit to be risked,
and so little to be gained, unless in a large field of operative practice.

I have likewise much pleasure in adding, that the volumes of the
Provincial Medical Association, in the variety and excellence of
the papers which they contain, afford a highly honourable view of the
intellect energy, and endowments of provincial medical men of all

classes.

THE SICK POOH,

advise on the many subjects of a professional nature which
must continually come before the Board. While parishes
acted separately, such a plan was impracticable ; but now
that the management of the poor is centred in one body, it is
difficult to see how the medical department can be efficiently,
or satisfactorily regulated, without such aid. The Commander-
in-chief of the Army, or the Lords of the Admiralty, would
never think of trusting solely to their own knowledge of
medical affairs, for managing concerns which relate to the
health of our soldiers and sailors. They depute this duty to
adequate and efficient men, who, while they leave the whole
power of the general regulating body untouched, are the con¬
fidential advisers of the heads of departments, and are a
guarantee to the public and the profession, for their having
every species of professional information placed before them to
direct their decisions. Your Lordship is by law the ultimate
arbiter in all matters connected with the Poor Laws ; but
with every deference to your Lordship’s knowledge, and to
your anxious wish to do every thing which humanity can
dictate for the good of those whose interests come under your
especial protection as the Secretary of Home affairs, I cannot
help being of opinion, that it would have been advantageous if
some of the points submitted to your consideration in the
annual reports, had previously come under particular pro¬
fessional cognizance. — I may deduce another instance of the
same division of duty, from the Court of Chancery, in which.

it is well known, that though the Lord Chancellor has the sole
right of decision on every point which comes before him, he
never acts on medical subjects, without medical advice.

I took the liberty, at the commencement of my letter, of
stating my impression, that the Poor Law Commissioners had
fallen into some misconception relative to medical men and
medical practice. I feel it to be no impeachment of the highest
fitness for exercising the most important public duties, that
there should not be a familiarity with all the details of a
purely professional nature, which may be connected with them.
Such an acquaintance is certainly never expected of the h i ah

24

THE RELIEF OF

public functioneries to whom I have just alluded. But more
particularly I consider it desirable, that the Poor Law Com¬
missioners, with the large mass of multifarious duties, which,
from the instant of their coming into office, has most severely
and constantly pressed upon them, should have had the means
of knowing something of the character, feelings, and preten¬
sions of the large, well-educated, and useful body of men, in
whose affairs they found it to be their duty to legislate. In
particular, they should have been minutely acquainted with
various important circumstances relative not only to medical
affairs generally, but medical attendance on the poor, which,
with every deference to their talents, powers of observation,
and experience, I consider it to be hardly possible that any
one, who has not been called upon to make such affairs his
particular study, can know with sufficient accuracy for im¬
portant practical purposes.

I do not at all wonder, that from the first of their coming
into office, the Commissioners should be impressed with the
absolute necessity of making retrenchments in every quarter.
To effect this object, appeared indeed to be a main and primary
object of their formation. The gravamen of the poor rates
has always been considered to be their magnitude, and this
supposed to arise, as well from extravagance in necessary
expenditure, as misapplication of relief to cases not requiring
it. In correcting the former, it must have been felt difficult
to act upon any other principle, than that every item should
be closely looked to, and unsparingly cut down. It could
hardly be imagined that parsimony and extravagance could
ever co-exist ; and that, while the great mass of expenses
required .curtailment, some particular ones were to be un¬

touched, or even augmented.

It was perhaps not altogether unnatural too, with the im¬
pression which the commissioners seem to have early imbibed
as to the mean and mercenary conduct of certain individuals
of the profession, relative to suspended orders, that the general
inference which they were disposed to form of the body at
large, was not a little disadvantageous; and that they might

THE SICK POOR.

25

hence feel themselves justified in applying the tradesmanlike
mode of contract and open tender, as a defence against selfish
and interested conduct. If it could be at all imagined, that
the habits and feelings of the profession generally, would con¬
descend to make a property of suspended orders, and to fee
4C inferior officers” — u to search out” for them, no means of
prevention could be conceived to be too harsh and too strict.
But without at all questioning the existence of an occasional
deviation from rectitude, from which even the sacred profession
itself cannot, from the infirmities of human nature, be in every
instance exempt, I must beg leave most respectfully, but most
firmly, to deny the propriety of the generalization at which
the commissioners have arrived on this subject, and the pro¬
cedure which they have in consequence adopted. Nor does
the result of my enquiries at all favour the supposition, that
the charge for suspended orders is usually either excessive, or
made at the highest rate of professional usage.* The suf¬
frages of all classes of society, from the throne to the cottage,
unite in stamping the feelings and conduct of the medical
profession in all its departments, with an honour, and probity,
a trustworthiness and decorum, which well merit the un¬
bounded confidence which are reposed in it. Hence it is
hardly a matter of surprise, that the profession generally should
feel hurt, by gentlemen of the endowments and character of
the Poor Law Commissioners, and of their elevated position in
society, entertaining any disposition to give credit to, or act
upon so unworthy an imputation as that which I have noticed.

By the second report of the Poor Law Commissioners it is

* Suspended orders in Norwich, when they were charged for
separately, amounted, I understand, to 120/. or 130/. per annum. In
many parishes and districts concerning which I had the opportunity
of making inquiries, the charge was trifling. The difference in the
expense of medicines to the rich and poor is principally in the form in
which they are given ; draughts being much more expensive than
mixtures, and therefore appropriated to the more wealthy classes. I
have every reason to believe, that in suspended orders, the more
expensive form was not given, and that the charges were those usually
made to the middle classes of society.

THE RELIEF OF

26

satisfactory to see, that in recommending the method of tender,
they disclaim any proceeding at all derogatory to the character
of the medical profession ; but at the same time I think it
must be fairly admitted, in justification of the feelings of
annoyance which have arisen on the subject, that in adopting
the practice in the first instance, in order to guard against the
unworthy conduct of some particular men, it was difficult to
view the proposition in the complimentary light in which the
explanation of the Commissioners has endeavoured to put it.

With regard to the opinion of the Commissioners, that the
office of parochial or district surgeon, is likely to offer induce¬
ments to obtain it, differing in degree, but similar in kind to
those presented by the chief medical institutions in the country,
I have every conviction that the united feeling of the profes¬
sion is not in accordance with this idea.

Hospitals and Dispensaries impart a considerable degree of
consequence to the offices connected with them, because those
offices are generally held by physicians and surgeons of rank
and estimation ; but at present, certainly, the collateral in¬
ducements to hold the appointment of parochial medical
attendant, cannot at all be viewed as superceding considera¬
tions of emolument. Most of the circumstances which give
dignity to the great medical situations of the country are
sufficiently obvious ; and it may be stated as an additional
ground of disparity between those offices and that of the sur¬
geon to the poor, that the finding and dispensing, and at the
same time sparing medicines, is a striking characteristic of the
latter, with which hospital physicians and surgeons have
nothing whatever to do.

But it may be remarked likewise, that independently of the
credit which attaches to the great medical appointments in
question, and which is supposed to afford a sufficient remunera¬
tion in the professional engagements to which it leads, there
is frequently a large and certain emolument arising to the
officers, and particularly the surgeons of charities, in the fees
paid by pupils for hospital attendance, and in the lectureships
with which hospital appointments are so often connected.

THE SICK POOR.

27

Since the Apothecary's Act of 1815 enlarged the education of
the general practitioner, and in particular made it obligatory
to have the benefit of seeing medical, as well as surgical prac¬
tice, not only has the attendance on physicians become much
increased, and their emoluments therefore augmented, but dis¬
pensaries have become, in many cases, extensive and valuable
schools of instruction, and in this way of pecuniary benefit to
the officers connected with them. The advantage derived
from pupils, is not however confined to London ; but takes
place, to a certain extent, in all the hospitals, and some of the
dispensaries of the country.

At the first establishment of hospitals, it appears indeed to
have been the plan, to make some pecuniary recompense to
their medical officers ; and even at the present day, I am
much mistaken if the original salaries are not still continued
in some, or all the royal foundations of Edward the sixth.
With the first formed dispensary of the metropolis, this was
also a part of the original constitution ; and whenever the
finances have allowed it, the practice is, I believe, still pursued.*

There is, however, an important difference between charities
which are dependent on the uncertainties of voluntary contri¬
butions, and such as are empowered by law to raise sufficient
funds for their expenses.

In the former case, though it is often difficult to keep up the
necessary pecuniary supplies, yet it is apparent that there are
considerable means of compensation always in reserve, for the
services rendered, independent of immediate and direct salaries.

There is likewise in the publicity of duties, in association
with colleagues, but most particularly in the watchfulness of
zealous, intelligent, and scrutinizing pupils, a strong stimulus

* The General Dispensary (which is still carried on, on the site of
Shaftesbury House, Aldersgate Street,) was the first establishment of
the kind in this country, and is only of the date of 1770. From
having been some years physician to this charity early in life, I
happen to know, that for a long period after its formation, a salary of
one hundred guineas per annum was paid to its medical officers, which
was only discontinued from a defect of funds.

TI1E RELIEF OF

to the exertion of talents and energy, and a powerful guarantee
against sluggishness and routine.

But the exercise of regular and laborious duties, unaccom¬
panied by the collateral advantages which I have had occasion
to notice, cannot be long depended upon without adequate
remuneration. There ought, as it appears to me, to be a
complete feeling of responsibility on the part of official persons
of every kind ; and a perfect and practical power of control on
that of their employers.*

This is the judicious principle on which parliament has in¬
variably acted in relation to ordinary and inclispensible duties;
and I have every hope and expectation, that under your Lord-
ship's auspices, the same humane and efficient arrangements
will be introduced into the provisions connected with the sick
poor, which pervade all the other parts of our social system,
in which medical relief or inspection are concerned. *f Much
more difficulty has been anticipated in making satisfactory
arrangements for parochial medical attendance, than it appears
to me can be practically found to exist. Medical men are

* In Norwich, as I have already stated, the medical attendance is
gratuitous ; but continual changes take place. At first these were
the services of physicians, but no one of that class will now accept
office ; and the poor are made entirely dependent on the younger class
of practitioners, who may he expected, like their predecessors, soon
to throw up their appointments, though the addition of a very trifling
sum to the annual expenditure, would render the attendance on the
poor very satisfactory.

I regret to be informed, that in the very opulent parish of Mary-
lebone, with a population of 122,000, (where it appears by the parlia¬
mentary returns, that the estimate of real property in 1815, was near
510,000/. per annum, and the poor-rates on the average of the three
then preceding years, about 40,000/. per annum) there has been the
singular and discreditable parsimony lately introduced, of withdrawing
all salary from the attending physicians, to whom 100/. per annum
were, I understand, in the habit of being previously paid.

t I have already adverted to provisions which respect medical
attendance on prisons; and may also notice an example of a similar
kind, in the medical arrangements connected with the insane, for
which the public are under so many important obligations to Mr.
Gordon, the member for Cricklade.

TIIE SICK POOR.

29

represented as being the best judges of the value of their own
time and services, and so they certainly are ; but this is like¬
wise the case with persons in other professions and lines of
life ; and it does not prevent those who may have occasion for
the services of the latter, from employing the usual means
of inquiry and observation, to satisfy themselves as to the
proper and reasonable extent of remuneration. The salaries
of auditors and relieving officers have been determined on
this principle, without tender, and without competition, ex¬
cept as to fitness for office ; though there has been as much
apparent disparity in the positions, and much more in the
ranks of life of candidates for the former appointments, (one
of them in this county being a baronet,) than can be expected
to exist in the medical profession. It would certainly have
been satisfactory and appropriate to consult independent mem¬
bers of the profession itself, as to what might be regarded
as fair elements for fixing on remuneration ; but I would
submit whether it is not somewhat ungracious to appear to
pay medical men a compliment by inviting them to fix their
own terms, when the opinion is to be employed, not in order
to communicate information for the purpose of assisting the
judgment of their employers in fixing on a fair and proper
remuneration, but to place gentlemen in opposition to each
other, that their services may be obtained at the smallest
possible amount. It is stated, indeed, that there is no
actual obligation to accept the lowest offer ; yet there is,
unquestionably, an implied one, unless for an adequate reason
to the contrary, which the good character and fair preten¬
sions of most candidates will necessarily make a very rare
occurrence. But even then the advantage is entirely with the
employer ; for the candidate contends in the dark, and with¬
out the usual benefits which attach to competitors for ordinary
contracts ; for he is generally made to understand that his
proposals are not to be beyond a certain fixed, and sometimes
very inadequate amount.

In considering the means by which any satisfactory conclu¬
sions can be arrived at in respect to the expenditure necessary

30

THE RELIEF OK

for administering medical relief, it seems to be perfectly dear
that attendance and medicines stand upon totally separate and
distinct grounds. The difficulties which appear to attach to
the subject, have very much arisen from not making this
separation. Gentlemen may be variously remunerated for
their time and trouble ; but the full value of medicines must
be paid for, if they are expected to be given. When that
most estimable man, Sir Edward Parry, was an assistant
commissioner, and met a large assemblage of persons in one of
the principal towns of this county, to elucidate the nature and
provisions of the poor laws, he was appealed to, I have been
informed, as the son of a very enlightened physician, to use
his endeavours to protect the profession, of which his father
was a distinguished ornament, from the degradation which
seemed to be preparing for it in some parts of the country.
Sir Edward felt the appeal very strongly, and in reply was
stated to have expressed the assurance, that it was far from
his wish to press harshly or injuriously on the medical man,
but “ that the Poor Laws'* Act was one of economy , and
therefore the profession must conform to it, as well as other
classes of society.*' But what, I would venture to ask, is
economy ? If, according to the expression of a distinguished
writer, it is u the parent of liberty and ease," it can only
become so by properly regulating, not by withholding neces¬
sary expenditure.

Should it be the intention in providing the medicines which
are to supply the poor, to continue the mode of contract, there
are still the means of obtaining information from hospitals and
dispensaries, and from gentlemen who have no interest in
making inacurate statements, as to what the lowest provision
of proper drugs, for a certain extent of demand, may fairly
amount to.* There is hardly a town in the kingdom, which

* It may be proper to state, that in hospitals, and very generally
in dispensaries, a set of prescriptions is in common use, which form
what is called a pharmacopeia pciuperum. This little digest of phar¬
maceutical practice, is useful in saving time; but its object is likewise
to bring together cheap formulae, as far as cheapness and efficiency
can be conjoined.

TOE SICK POOR.

31

contains five thousand inhabitants, where there is not now a
dispensary ; and as institutions of this kind are managed with
every proper regard to economy, there could be no difficulty
in ascertaining what their expenses are, and in making such
modifications of their arrangements, as may at once accord
with the convenience, and be subservient to the efficiency of
parochial practice.

But I would submit that it would be in every respect better
to adopt the plan which has been long invariably followed in
the army and navy, where drugs are supplied in certain specified
quantities to ships and regiments, under the sanction, and by
the authority of high and responsible professional advisers, by
which means there has been a regularity and precision univer¬
sally introduced into the service, which are eminently favorable
both to the scientific and humane exercise of the profession.

The total interdiction of tender, and the determination to
allow the full value for medicines and curative applications of
every description, would be a great improvement in parochial
practice ; and though it would still leave an important arrange¬
ment to be determined upon, that of compensation for at¬
tendance, yet the consideration of this circumstance would be
rendered comparatively easy, when it was once unfettered by
the various collateral matters with which it has been usually
encumbered.

It is only under particular circumstances that parliament
fix the amount of salaries ; but if they would condescend, as
in the case of chaplains to prisons, and medical inspectors of
lunatic establishments, to point out the extent of remuneration
for parochial medical duties, according to some particular scale,
this would, without doubt, be the most satisfactory mode of
proceeding. If, however, in defect of such absolute appoint¬
ment, they should direct a reasonable and adequate stipend to
be paid for parochial attendance, and leave it to the Home
Secretary, under his responsibility as a minister of the crown,
to fix the precise amount, I have no doubt that the surgeon
to the poor would, in this way, be fairly and honourably re¬
munerated. In all matters which concern medical attendance,

32

THE RELIEF OF

as far as the Court of Chancery is concerned, the Lord Chan¬
cellor himself determines the details, under such advice as he
may require ; and there seems to be no reason why the Home
Secretary, as having peculiarly the care of all the domestic
interests of the country, should not be authorized to follow
the same plan.

I have already noticed the circumstances which seemed to
show that the Poor Law Commissioners, at the time of their
appointment, did not enter with perfect precision into the
character of medical men, and medical arrangements. And had
this not been the case, 1 have no doubt that they would have
been full as successful in giving satisfaction, when medical
gentlemen were concerned, as in the case of relieving officers,
auditors, and assistant commissioners ; but, under the present
circumstances, they would hardly feel it delicate or satisfactory
to have any concern with the direction of medical salaries ;
though I have no doubt that they would, under a strong indi¬
cation of the feeling of parliament as to the necessity of ade¬
quate remuneration, put aside any peculiar opinions of their
own on the subject, and carry into effect such indication, with
scrupulous honour and good faith. Least of all, however,
does it appear to me proper to entrust to Boards of Guardians,
the appointment of medical salaries ; for with every sentiment
of humanity with which I believe them to be possessed, as far
as the interests of the poor are immediately concerned, and
with the most correct and liberal feelings in their individual
capacity, they often seem disposed to consider it in perfect
accordance with the honourable discharge of their duties, to
look to the trifling savings withheld from the clergy, or from
the medical attendant on the poor, as matter of much self
gratulation, and great public benefit. They do not seem to
bear in mind the highly important and interesting duties at¬
tached to the former, and that the liberal provisions of parlia¬
ment in respect to them, should be made as much as possible
a subject of imitation ; nor do they appear to be at all aware
how much the interests of humanity, in what concerns the
poor, are dependent on making a reasonable and proper, as
well as respectable return, for the services of the latter.

THE SICK POOR.

33

But when measures are brought forward which will occasion
any considerable augmentation of expense, I am aware that
financial difficulties, of a nature hardly to be overcome, will
sometimes oppose themselves to the most wise and benevolent
intentions of the statesman. I have already mentioned my
belief, that a fair and proper recompense for medical services,
would make a very trifling addition to the amount of the poor-
rates. I may state as a proof of this opinion, a fact which has
come within my own immediate knowledge, namely, that in
order to double the stipends of the medical officers of an union
in the county of Norfolk, (and which in no way differs from

icipal
sums

respectively of 5s. KM. and 17-s. 6d. per annum ; and this
when the poor-rates have been reduced about one-third since
the introduction of the new poor laws.*

And yet it is such trifling savings that have been made to
interfere with the interests of humanity, and with the credit
of an honourable profession.

I trust, therefore, that your Lordship will be of opinion,
that no financial difficulties can be expected to present them¬
selves in the way of effecting such changes as it may be thought
proper to adopt, for any real and substantial improvement in
the medical arrangements connected with the poor. But there
are a few other considerations, to which I am desirous of
directing your Lordship's attention, in an attempt to render
medical attendance more effective. One is, that districts
should not be too extensive ; for there is necessarily a limit
both to bodily and mental exertions.

* The district is that of Loddon and Clavering, and the parish is
that in which I reside. The whole rates amount to 6494/. per annum,
according to the last report of the Poor Law Commissioners * those
of the parish to 254/., and the medical salaries to 210/. of which 8/. 4,9.
are the share of the parish in question. The assessment of the two
parties mentioned, are reciprocally about 100/. and 300/., the whole

parish assessment being about 2900/., and the number of acres about
2100.

C

the average of the county) it would only cost the pri

n » 'S-'f

ew lie*’, and principal occupier oi a particular parish, the

34

THE It El, I EE OF

Long and fatiguing journeys over large tracts of country
and hurried visits to very numerous patients, may satisfy the
superficial observer as to the attention and assiduity of the

9s

practitioner, hut otter little real advantage to the patient, in
cases which call for thought, discrimination, and skill. Such
sort of practice, instead of schooling the mind to accurate ob¬
servation, on which so much of the efficiency of medical prac¬
tice depends, is very likely to do it the most essential injury,
and to convert the best endowed, and best intentioned student,
very speedily and irretrievably, into the superficial and ineffi¬
cient routinist.

The experienced practitioner will see, at one view, the
essentia] points of a case ; hut a young man, however well
educated he may be, can only obtain this facility of apprehen¬
sion, by great attention in early life, and in particular by
having his observation at first directed to only a small number
of cases.

A point in some degree connected with this, I would like¬
wise beg leave to notice, which is, that parochial duties should,
as much as possible, be confined within the limits of ordinary
professional avocations, for then the character of medical gen¬
tlemen is well known ; and it is a gratification to poor persons
who may have been in the habit of looking up to particular
individuals with respect and regard, to have the benefit of
their advice and attendance.

The smaller may be the district, the smaller must necessarily
be the extent of the remuneration ; but it never need be so
small as not to afford sufficient scope for the public duties of a
practitioner, who must still be expected to look to private
practice for his proper and effectual recompense.

If, therefore, the Poor Law Commissioners would employ
the influence of their high situations to improve the state of
the profession, and to promote its successful cultivation among
the junior practitioners, I would respectfully submit these par¬
ticular points to their serious and attentive consideration. I
have suggested, in a previous part of my letter, the propriety
of having a medical gentleman of experience connected with

THE SICK POOR

35

the Poor Law Commission, as in other public departments,
when medicine is at all concerned. I beg to add upon this
subject, that if any such measure were approved by your
Lordship and Parliament, it might be rendered subservient
to much public benefit, by affording the means of turning to
some public account, the great mass of important observations
to which well regulated parochial practice might be expected
to give rise.

The report given of the successful establishment of inde¬
pendent medical clubs, in a great number of Unions, is par¬
ticularly gratifying ; but I cannot, I must own, view the
exhibition of medical relief to poor persons, any more than
giving them the advantages of education, as productive of the
evil consequences, which from some observations contained in
the Commissioners' Report, appear to be feared from them.*

* A very zealous, and able Poor Law Commissoner, with whom I
have the pleasure of being acquainted. Dr. Kaye, attributes, in a very
interesting memoir on Suffolk and Norfolk, which appeared in the
second report of the Poor Law Commissioners, a very unfavourable
influence to the facility of obtaining medical relief, which well sup¬
ported hospitals, and other means of providing it, afford ; and he re¬
gards medical relief as “a form of pauperism, which is the more
dangerous, since it habituates the poor to dependance, under cir¬
cumstances which cloak the tendencies of the system.” He states
that in Manchester, and its adjacent townships, (the population of
which, in 1831, amounted to 230,000 inhabitants,) there is at present
an annual medical expenditure of 18,000/., which has much increased
of late years, and is still likely to go on increasing, and he adduces
some other places in corroboration of his views.

The careful examination of Dr. Kaye’s conclusions, relative to the
effects of medical relief, in which I have the misfortune, but with
every feeling of respect, very much to differ from him, would carry
my appended observations too far. I must satisf>^rgvself, therefore,
with remarking, in addition to what I have said afryago 18 7^ that the
disposition to seek for medical aid may arise from other causes, in a
flourishing town, than a tendency to pauperism. It may be connected,
for example, with an augmented estimate of the utility of the profes¬
sion, a dislike to empiricism, and an increased value for the skill of
the physicians and surgeons who exercise it in medical charities, and
who occupy, generally, the first rank in their profession.

With regard to the apparent magnitude of the sum raised, in pro¬
portion to the population, it does not appear to me by any means equal

36

THE RELIEF OF

I am very averse to consider as paupers, persons who merely
receive medicines or instruction from the public. Nor ought
the noble hospitals, and other medical establishments of which
our country has so much reason to be proud, to be viewed as
at all accessary to the demoralizing operation of pauperism.

The means of having medical relief and education, should,
I would submit, be as little narrowed as possible ; and with all
the advantages which sober habits, strict economy, and a
general elevation in the scale of social beings will produce, it is
difficult to conceive that an agricultural labourer, earning at
most 9s. per week, of which he pays Is. or Is. 6d. for his
cottage, can be beyond the necessity of receiving, in sickness,
medical as well as other aid. Under such circumstances, I
have every reason to believe, that the Poor Law Commissioners
will give their complete sanction to the relief being adequate
to the occasion ; and I am happy in having it in my power to
state, that I have never, either in town or country, applied to
Overseers or Guardians on behalf of sick persons, or such as
from age or infirmity were unable to do any thing for them¬
selves, without the most humane attention being paid to my
representations.

The various means now in operation, for elevating the con¬
dition of the labourer, will, I trust, have an extensive and
beneficial result; but time is required for the object, and I would
also say, a greater increase of wages than has yet taken place.

But there is one subsidiary point to which I am anxious to
direct your Lordship’s particular attention, and that is the in¬
crease of appropriations, (for I dislike the perverted term of
allotments) of a small quantity of ground, as a quarter of an
acre, for' a cottage garden. A labourer would be willing to
pay even double the ordinary letting value for such a portion
of ground, and the advantages produced by it would be in¬
calculable, in filling up his spare time, employing his family,
and furnishing himself with work in uncertain weather, or

to the medical expenses of London, which, with its population of
1,400,000, would, at this rate, have an expenditure in medical charities
under 110,000/. per annum ; nor do I apprehend it is much, if at all
greater, than that of most other provincial towns.

THE SICK POOR.

37

when lie cannot procure it elsewhere. He would thus be
enabled very

operation, for bettering his situation, and increasing his inde¬
pendence ; and would have it in his power, more readily, and
more effectually than by any other means either in use or
prospect, to provide the funds necessary to prevent him from
ever having occasion for parish relief.

It would be of great importance that the Poor Law Com¬
missioners should give their powerful aid, to the furtherance
of this object ; and if the assistant Commissioners, under their
auspices, would avail themselves of their visits to unions and
parishes, to impress on landholders and farmers, how subser¬
vient distributions of small portions of land as gardens, at
almost any rent which could be set upon them, would be to the
comfort of the poor, and the favourable operation of the Poor
Laws, the measure (which with its other recommendations,
would be exceedingly popular among agricultural labourers,)
would have the prospect of being soon very generally adopted.

I am sensible, my Lord, of having trespassed too much on
your time, by the extent of my observations, and I would
therefore, in conclusion, merely express the hope, that an
opportunity of obtaining medical relief should still be allowed
to the labourer and workman, to the full extent of the demand,
without too nicely balancing any mixed considerations, relative
to the ultimate effects of the practice. When the position of
the lower orders becomes more elevated, their feelings of in¬
dependence increased, and the success and advantages of
medical clubs more generally known and experienced, the
necessity for having relief from the parish surgeon, and at the
expense of the parish, will necessarily cease, or be much
diminished.

I have the honour to be,

With high respect,

Mv Lord,

Your Lordship’s faithful and obedient servant,

J. YELLOLY, M.D.

Woodton Hall, Norfolk, Feb. 11th, 1887.

effectually to assist the endeavours now m